Provider Demographics
NPI:1851644538
Name:CHAGOURY, RIANA LEAKE (MA)
Entity Type:Individual
Prefix:
First Name:RIANA
Middle Name:LEAKE
Last Name:CHAGOURY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SCHRADER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6213
Mailing Address - Country:US
Mailing Address - Phone:323-860-5844
Mailing Address - Fax:
Practice Address - Street 1:15030 7TH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3811
Practice Address - Country:US
Practice Address - Phone:833-438-8763
Practice Address - Fax:833-438-8700
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA32343103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01261511Medicaid